Abdominal pain secondary to bilateral adrenal haemorrhage as the first presentation of antiphospholipid syndrome

A 39‐year‐old man presented to the emergency department with a three‐day history of anorexia and severe abdominal pain, which was worse in the right lower quadrant. He had an upper respiratory tract viral infection two weeks before this presentation. Past medical history was significant for mixed connective tissue disease, which was diagnosed 27 years ago and was being monitored. On examination, he was afebrile and normotensive, and demonstrated generalised abdominal distension, guarding and tenderness on palpation. Investigations showed normocytic anaemia with haemoglobin 103 g/L (reference interval [RI], 130–180 g/L) and marked neutropenia 0.5 × 10⁹/L (RI, 2.0–7.5 × 10⁹/L). He had an elevated C‐reactive protein at 391 mg/L (RI, < 5 mg/L) and a prolonged activated partial thromboplastin time (APTT) of 44 seconds (RI, 23–33 seconds) that did not correct on mixing studies.